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Exhibits

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The client has rested well throughout the night with a continuous positive airway pressure (CPAP) device in place. Sequential devices are in place for venous thromboembolism prevention. The client ambulated 100 yards (91 meters) last night and 200 yards (183 meters) this morning.

She reports pain rating of 2 on 0 to 10 scale, located in the abdomen, described as aching. She has tolerated fluids throughout the night with no nausea or vomiting.

Assessment

Neurological Alert and oriented times 4. Cardiovascular WNL

Respiratory WNL

Gastrointestinal/Genitourinary Voided twice throughout night

ambulated 100 yards (91 meters) last night and 200 yards

pain rating of 2

tolerated fluids

Alert and oriented times 4

Voided twice

Respiratory WNL

Cardiovascular WNL

no nausea or vomiting

Answer and Explanation

The Correct Answer is ["A","B","C","D","E"]

The client has rested well throughout the night with a continuous positive airway pressure (CPAP) device in place. Sequential devices are in place for venous thromboembolism prevention. The client ambulated 100 yards (91 meters) last night and 200 yards (183 meters) this morning. She reports pain rating of 2 on 0 to 10 scale, located in the abdomen, described as aching. She has tolerated fluids throughout the night with no nausea or vomiting.

Assessment

Neurological Alert and oriented times 4.

Cardiovascular WNL

Respiratory WNL

Gastrointestinal/Genitourinary Voided twice throughout night

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is D

Explanation

A. Infection: While infection can cause localized redness and swelling, deep vein thrombosis (DVT) is a more likely cause given the client's immobility and other risk factors.
B. Fat emboli: Fat emboli typically occur after trauma or orthopedic procedures, and their presentation is less likely in this scenario.
C. Pulmonary embolism: While a pulmonary embolism is a potential complication of DVT, it presents with symptoms such as dyspnea, chest pain, and tachypnea, rather than localized redness and swelling in the calf.
D. Deep vein thrombosis: This condition, characterized by redness and swelling in the affected limb, is common in immobile patients and those with dehydration, making it the most likely cause of the client's symptoms.

A. The client's daily blood pressure will be less than 140/80 mm Hg this month. B. The nurse will encourage the client to walk thirty minutes every day. C. The client will monitor blood glucose and blood pressure after each meal. D. The client's blood pressure readings will be less than 160/90 mm Hg.

Correct Answer is A

Explanation

A. A goal of maintaining a blood pressure less than 140/80 mm Hg aligns with recommended targets for clients with cardiovascular disease to reduce the risk of complications.
B. While physical activity is beneficial, stating that the nurse will encourage the client to walk is not a measurable client-centered outcome. A better outcome would focus on the client’s actions.
C. Monitoring blood glucose is more relevant for diabetes management rather than a primary outcome for cardiovascular disease.
D. A target of less than 160/90 mm Hg is too high and does not align with standard guidelines for blood pressure control in cardiovascular disease.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is completing an admission assessment on an older adult client with dehydration, failure to thrive, and who is immobile. The nurse reports to the healthcare provider that the client's right calf is red and swollen. The nurse should suspect which probable cause of these findings?

Correct Answer is D

Explanation

The nurse is developing a plan of care for a client who reports chest pain on exertion and who is newly diagnosed with cardiovascular disease. Which outcome should the nurse include in the plan of care for this client?

Correct Answer is A

Explanation

A client with a history of unstable angina presents to the emergency department with constant chest pressure that is unrelieved with rest. The client appears anxious, pale, and diaphoretic. After obtaining the client's vital signs, which action should the nurse take next?

The nurse is conducting Intake Interviews of children at a city clinic. Which child is most susceptible to contracting lead poisoning?

An older adult client arrives at the clinic describing a new onset of urinary incontinence. Which intervention should the nurse implement?

A new mother on the postpartum unit runs out of the room screaming that her newborn infant's crib is empty and the baby is missing. Which action should the nurse take first?

Exhibits Based on the assessment and blood gas results, which 3 orders should the nurse expect from the healthcare provider?

Two weeks after returning home from traveling, a client presents to the clinic with conjunctivitis and describes a recent loss in the ability to taste and smell. The nurse obtains a nasal swab to test for COVID-19. Which action is most important for the nurse to take?

When admitting a client with a diagnosis of transient ischemic attack (TIA, which intervention is most important for the nurse to include in this client's plan of care?